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Clinical Lecture on Abdominal Neuralgia. By HANDFIELD JONES, M.D., Physician to St. Mary's Hospital.

invariable success; for I have known the fragments of the sac restored to their original places, and the disease remain in statu quo. I advise you to adopt in great This series of cases is interesting as preference to this coarse and old-fashioned illustrating the diagnosis and treatment of treatment the following, which rarely fails a disease that is not always easy to disto obtain an early, if not an immediate, tinguish from other affections in which cure. Its object is to evacuate the entire pain is referred to the abdomen, especicontents of the cyst, and to bring its oppo- ally peritonitis, lead colic, and hysteria. site surfaces into perfect apposition with The points on which Dr. Jones chiefly each other. It is a small operation; but insists appear to be-1. That the region on the delicacy of its performance its of the abdomen, probably its peritoneal success materially depends. Bending the lining, is liable to suffer from neuralgia hand forwards, in order to tighten the and hyperesthesia, such as prevail in skin over the cyst, pass vertically into other situations more notoriously prone the centre of the tumour a broad-shoul- to this malady. 2. That such neuralgic dered lancet. By a lateral movement of affections may very closely simulate perithe instrument the orifice will be dilated, tonitis. 3. That they may be attended and the contents will freely escape. Now with high temperature. 4. That they it is indispensable to the obliteration of may possibly pass into peritonitis. 5. That, the cyst that the whole of its contents in their treatment, opium (preferably in should be evacuated-every drop and the form of enema), tonics and restoraevery fraction of a drop, to effect which tives prove to be successful remedies. the sac must be compressed and kneaded The first case is that of M. Win every direction. Then apply a well-aged forty, a married woman, who was made thick compress of lint, and strap it admitted on the 9th September. She down tightly with good plaster, and, stated that three days previously she had lastly, a roller may be applied. In forty- been seized with pain in the lower part of eight hours the wound has healed, and the abdomen and the hips, so violent as the ganglion is seen no more. to draw her double; since the day before

In cases (and I suppose I have operated | admission it had been gradually subsidon a hundred) in which the operation I described failed to cure the disease, the ganglion, as it will do when of long standing, had burrowed under the tendon. In one of these I attempted to dissect it out; but, in so doing, I denuded the tendon of its natural investment, and the result was permanent union between the tendon and integument. I never recall the circumstances of this case, and it occurred upwards of twenty years ago, without painful regret. The larger examples of a similar affection to the above-in which the synovial sac, probably the anterior one, which extends beneath the anterior carpal ligament into the palm of the hand, is the seat, and from which abundance of small melon-pip like bodies are obtained -may be treated on the same principle. But the subsequent pressure must be great.-Lancet, Aug. 27, 1870.

ing, but with occasional aggravations. Whilst the pain was at its worst the abdomen had been so exquisitely tender that she could scarcely draw her breath, and whilst sitting up she had felt sick. On admission she flinched violently when the left side of the abdomen was touched, and she felt pain on coughing or drawing a deep breath; when she turned on to the right side she experienced a feeling of dragging in the left; the tongue was thickly coated with white fur; the pulse was 78, and not very weak; the temperature 99.3°; there was no blue line on the gums. The right side of the abdomen was resonant, the left dull, and these sounds were not altered when she moved on to her right side. She had no appetite, but was very thirsty; the bowels were habitually confined; the urine was very red, and passed with pain; there was also pain on passing her motions; the catamenia had not appeared for six

weeks, but she had a profuse leucorrhoeal | had a copious leucorrheal discharge, and discharge. There was no history of lead poisoning. She said that she lived over some stables, and had experienced a similar pain several times during the past three or four years; she felt very weak, and the least thing threw her into a “fainting perspiration." She had not been able to sleep during the previous night because dreadful sights appeared directly she closed her eyes-"blood and all that sort of thing, mice running about," &c. The bowels were first relieved by an aperient, and then an enema containing twenty drops of laudanum was administered, and followed by a great abatement of the abdominal tenderness. The treatment was then made to consist of onetwentieth of a grain of strychnia, one minim of nitric acid, and ten of chloric ether, in an ounce of water, four times a day; with simple diet, a pint of milk, and four ounces of sherry. On the second day her sleep had been disturbed in the same manner as before; the abdomen was quite soft and only slightly tender. On the third morning the sleep had been sound and uninterrupted; the bowels were relieved by an enema, and the diet was changed to chop, pudding, and porter, the medicine to twenty grains of the saccharated carbonate of iron, three times a day. On the seventh she was still improving, but, on getting up, the pain and feeling of faintness returned slightly. In a few days more she was discharged.

was suffering such intense pain that six leeches were immediately applied to the abdomen, and followed by poultices. On the 13th Dr. Jones found her very weak, complaining of great pain on the left side of the abdomen, but lying with the legs extended; the left flank of the abdomen was dull on percussion; the other regions were resonant. The pulse was 102, not very weak; the temperature 102.5°; the tongue moist. There was no flush on the cheeks nor eruption on the abdomen. The bowels had not been open for two days; the appetite was good; the breasts did not secrete much milk. She was ordered an enema of castor oil, to be followed, after the action of the bowels, by a simple enema containing twenty drops of the tincture of opium; also a draught of four grains of carbonate of ammonia and one drachm of tincture of bark, in an ounce of decoction of bark, three times a day, with a generous spoon diet. On the fourth morning she awoke in great pain from a sleep which had lasted from early in the previous evening. The pulse was 105; the temperature 103.4°. The abdomen was fomented, and another opiate enema administered, and she was ordered twenty grains of the saccharated carbonate of iron thrice daily, in addition to the draught. On the seventh day the pulse was 88, the temperature 99.7°, and pain of a much less severe character recurred from time to time. The diet was changed to one of meat and porter. On the eleventh day the temperature was 100°, and, in consequence of copious night-sweats, the ammonia-and-bark draught was abandoned for one containing four grains of quinia. Subsequently a chloride-of-zinc injection was made use of to check the leucorrhoea. Twenty-eight days after admission she only complained of an occasional return of pain towards evening. No blue line was observed at any time on the gums.

The second case was that of A. N—, aged twenty-six, a married woman with three children. She was admitted on Sept. 10th, and gave the following account of herself: She was in charge of a house which had just been painted, and smelt strongly of paint and varnish, when, three weeks before admission, she was attacked with severe headache, which, two days later, was replaced by an abdominal pain which she described as having been frightful in severity, and since its The third case was also a woman, thirtyonset she had been unable to lie on either three years of age, and single. She side, or to obtain sleep at night. She had stated that she had been indisposed for a been feverish and without appetite. No fortnight, and had kept her bed for a other inmate of the house had been out week. The first symptom had been pain of health. She looked thin and anæmic, at the upper part of the abdomen, all

round it, and in the back, great pain also followed on taking food, and was relieved by vomiting. At the time of admission the pain seemed to be violent; she was found to be bending herself down and moaning; the tongue was moist, and tolerably clean; the pulse 80; the temperature 97.5° F. The abdomen moved a little in respiration, but the muscles were at times very hard and tense; there was no eruption. She had no appetite, but was very thirsty. On inquiring into her history, it was elicited that seven years before she had lived in a house whilst it was being painted, and that she suffered at the time some nausea; also, that two years before admission she had suffered, for a short time, a somewhat similar kind of pain. The teeth were found to be so incrusted and soiled with tartar that it was difficult to determine whether or not a blue line was present. She also complained that for a year she had had pain about the rectum, accompanied by a frequent desire to defecate; but she had never experienced any pain during the passage of her motions. The uterus was found to be reclined, the fundus lying near, if not upon, the rectum. She was first ordered a grain of opium every four hours, ice to swallow, poultices to the abdomen, and subcutaneous injection of ten minims of solution of opium; but neither these remedies, nor an opiate enema which had been administered, were found on the following day to have afforded relief. She was found to be twisting and writhing in bed, although the abdomen bore pressure fairly well. The pulse was 72, and not weak; the urine clear and of high colour. She was then ordered a drachm of tincture of valerian and four grains of carbonate of ammonia in an ounce of infusion of valerian, thrice daily; but she obtained no sleep during the following night, severe pain being excited every time she moved; and, in the morning, the abdominal walls were found to be hard and retracted. The temperature was 98.9° F. An opiate enema was followed by relief, and a grain of opium was ordered to be taken every two hours. On the eighth day two grains of iodide of potassium were added to the draught. On

the fifteenth she was ordered in addition twenty grains of saccharated carbonate of iron, thrice daily. On the sixteenth day the pains became regularly paroxysmal, returning morning and evening at half-past ten o'clock. On the same date she began to sweat a great deal at night; ten grains of quinia daily, in two evening doses, reduced the severity but not the duration of the attacks. The amount of quinine was then doubled by giving four doses daily instead of two, and by the twentieth day she was free from pain and improving in general condition. ter this the pains returned slightly, and a treatment as for lead colic was essayed, but, proving unsuccessful, was changed for citrate of iron and quinia, under which they soon began to disappear; and within little more than a month from the date of admission, though the patient suffered occasional returns of pain, the abdomen was soft and mostly quite free from tenderness on pressure, and she was discharged at her own request.

Af

These cases, Dr. Jones said, were fair specimen cases of a disorder which is by no means rare, at least among the poorer classes. In calling it "abdominal neuralgia" he had followed unwittingly the example of the late Dr. Addison, who had written a very full and interesting paper on the same disorder in connection with uterine irritation. The term might be thought too vague, but he preferred it to any other, for the reason that it did not appear to him that any organ is specially affected, and that any part of the region in question might be attacked. If he were pressed to localize the disorder more exactly, he should name the peritoneum as the most probable seat, partly on account of the quality of the pain, partly because this membrane is coextensive with its situation. Romberg had described a hyperæsthesia of the mesenteric plexus, but the description he gave of it seemed more applicable to the colic than to the malady they were considering. A perusal of the cases, Dr. Jones thought, indicated that the resemblance of the symptoms, especially the pain, to those of peritonitis was quite close enough to make the diagnosis sometimes sufficiently difficult.

Dr.

most singular appearance from the thousands of leeches" which at various times had been applied. A very important question might be raised-viz., whether a primarily neuralgic disorder may not pass into an inflammatory. Dr. Jones's belief was that it might, and though he had not observed it in abdominal cases, yet there was considerable evidence, he thought, that such a change may occur in facial neuralgia. For further remarks on this topic he referred to his work on the subject. Some might be disposed to look upon these cases as examples of hysteria, and would have summarily dealt with them by the treatment which Sir T. Watson recommends-namely, purging followed by an assafoetida enema. To this he altogether demurred. If any definite meaning was to be attached to the term hysteria, it must imply that the patient's will was defective, that she was not sincerely anxious to get well; that, in fact, she wanted moral treatment more than medicinal.

Addison had said that the pain occasion- | quisitely tender. The case had been really attacked the whole of the belly, ex-garded as one of chronic peritonitis, and actly simulating acute peritonitis, and the surface of the abdomen "presented a that he knew of no more puzzling disease. The points which would prove most serviceable as guides were the previous history, the temperature, the posture, the respiration, the pulse, and the physical signs. If the patient appeared to have suffered from any cause of exhaustion, such as lactation, profuse leucorrhoea, over-exertion, semi-starvation, or the like, a neurosis was a more probable result than inflammation. If the disease was of long duration, such as from two to three weeks or more, and the pain persisted with severity, especially without the development of any other symptom, it could not be peritonitis; the same would probably apply if there was a history of several similar previous attacks. If the temperature underwent no rise, it afforded strong evidence against the existence of inflammation, though a high temperature could not by any means be taken to prove the converse. The second case indicated a temperature befitting typhoid fever, and it was only the sequel which conclusively showed that the pain was purely neurotic. It had been supposed that neuralgia could not coexist with pyrexia, but he had recently seen a case of ephemeral fever in which the patient complained of agonizing pain in the limbs, and the temperature rose to 1030; on the day following the pain had greatly abated, and the temperature was found to be normal. As regarded posture, the peritonic patient was said to lie in a fixed position, instinctively avoiding the slightest movement; the neuralgic often turns and writhes about the former abstains from using the diaphragm in respiration, the latter does not, or, at any rate, not to so great an extent. After a few days the physical signs would probably afford decisive information. The dulness in depending parts of the abdomen, due to effusion, is not present in neuralgia. So, also, abdominal distension may be looked for in peritonitis, but not usually in neuralgia; though Dr. Addison speaks of a very marked instance of the latter, in which the belly was as tense as a drum and ex

Such, he was satisfied, was

not the case with the patients in question. The pain felt was, as far as he could judge, as bonâ-fide a pain as ever racked a sufferer from sciatica or tic douleureux; they recovered speedily, and under such treatment as was known to benefit neuralgia elsewhere.

The occurrence of some amount of nocturnal delirium, and that of a terrifying and distressing kind, in the first case, Dr. Jones added, deserved remark. Such disorder was, if he might use the term, quite homogeneous to neuralgia, both affections having their root in a feeble paretic state of nerve-centres, and being as it were branches of the same stock. The derangement, in fact, was of the same kind in both, and the diversity of phenomena depended on the site of the morbid action; the intellectual centres being affected in the one case, the sensory in the other. There were also indications that the vaso-motor nerve-centres were involved, and suffered in a like way; for the patient in the first case complained of "faint perspirations"-i e., perspirations

attended with a sense of faintness; and in the second, of copious nocturnal sweating, precisely such as is met with in maladies of exhaustion.

Another noteworthy point observed, especially in the first case, and which Dr. Jones said he had not unfrequently met with in other unquestionable neuralgias, was the reproduction of the pain by exertion. This depended on the fact (for such he held it to be) that consumption of nerve-force in one centre, or, to speak more correctly, of material qualified to generate nerve-force under oxidation, diminishes its production in another, and so favours the recurrence of a disorder which is essentially dependent on the failure of nerve-force.

The special cause of the disorder in these cases could not be said to be clearly ascertained. It might be thought that the second was of lead-poisoning, as the patient had been exposed to the smell of paint; but he could not take that view. There was no notable constipation, and no blue line on the gums. The pain was not like that of colic; it was attended with fever, followed by copious nightsweats, and cured by tonics. He had never seen anything like this in the frequent cases of lead disease he had met with. The lactation and leucorrhoea no doubt had materially promoted the action of the exciting cause.

The diagnosis once made, the remedies to be used were plain. Opium to relieve suffering, tonics to restore strength, the action of both being led, rather than seconded by repose and good nourishment. In doubtful cases, after ascertaining that the bowels had been sufficiently cleared, he advised the use of an opiate enema before applying leeches. The result of this means might be so satisfactory as to make the further treatment clear. On the other hand, it was to be observed that in a puzzling case Dr. Addison thought it an error on the right side (for an error it proved to be) to employ the remedies for peritonitis. The few leeches which were applied in the second case gave relief; but he, nevertheless, thought they were unnecessary and undesirable. It was by no means impossible for such means, by

the temporary benefit they produce, to betray the practitioner into their repetition, with ultimately disastrous consequences.-Lancet, Nov. 19, 1870.

HOSPITAL NOTES AND GLEANINGS.

Cases in St. Bartholomew's Hospital, with Clinical Remarks, by Dr. ANDREW. Aneurism.-On examining a patient who was the subject of an aneurism situated in the left half of the chest, Dr. Andrew expressed the opinion that a considerable thoracic tumour in that situation inevitably causes obstruction of the thoracic duct. He had heard Professor Turner, of Edinburgh, express the same opinion; and had himself on two occasions endeavoured to inject the duct in similar cases, and found it completely closed at the site of the tumour. And he suggested that the obstacle thus presented to the supply of new material to the blood might have at least a share in inducing the well-marked cachexia which patients suffering from aneurism often present.

He

Suppuration without hectic.-Dr. Andrew drew attention to the absence of any symptom of hectic in a patient in whom a purulent discharge was being continuously evacuated by expectoration from the right pleural cavity, the patient being also the subject of pneumothorax. said that hectic is by no means a necessary accompaniment of even profuse suppuration. If, however, pus, or even mere serous fluid, were confined in a cavity, or ceased to be of laudable quality, a constitutional effect would at once be found to ensue. With reference to this subject one of the house-physicians who was present said that a patient of Dr. Harris's had been recently tapped for a suppurating hyatid of the liver, and that the fluid, having accumulated at the rate of a pint a day, had been removed by occasional subsequent tappings. At first the patient exhibited a most voracious appetite, and appeared to suffer no ill effect from this profuse discharge; but on a certain day, her appetite failing, she refused her large allowance of food, and in the course of a few hours her temperature rose, she became hectic, and daily

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